How the Plan Works
In general, the plan works as follows:
- You become disabled from an injury or sickness as defined below.
- You file a claim for short term disability benefits with Lincoln Financial.
- Lincoln Financial will determine if you are eligible for a weekly STD benefit.
- If Lincoln Financial approves your claim, you will receive a weekly STD benefit following the 7-day elimination period.
- You will receive the weekly STD benefit until you are no longer disabled or the end of the 52nd week of disability, whichever comes first.
Eligibility to Receive Short Term Disability Benefits
To be eligible to receive a weekly benefit under this plan, you must meet all of the following conditions:
- The injury or sickness that causes your disability occurs while you are covered by this plan.
- You are disabled as defined by the plan.
- You provide proof to Lincoln Financial that you are disabled, which includes but is not limited to:
- A completed claim form,
- A completed attending physician's statement, and
- Any additional medical evidence that supports your claim for benefits.
- You are under the regular attendance of a physician.
- You are receiving appropriate available treatment.
Basic weekly earnings
For Field Sales Representatives, basic weekly earnings means your gross weekly earnings before any deductions for a 401(k) or Section 125 plan as of the day before the disability begins. Commissions and bonuses will be averaged over the 52-week period preceding the disability, or your period of employment if you have worked less than 52 weeks. Overtime pay and any extra compensation are excluded.
For non-Field Sales Representatives, basic weekly earnings means your gross weekly earnings before any deductions for a 401(k) or Section 125 plan as of the day before the disability begins. Bonuses will be averaged over the 52-week period preceding the disability, or your period of employment if you have worked less than 52 weeks. Overtime pay, commissions, and any extra compensation are excluded.
Disability
Disability means that as a result of injury or sickness, you are unable to perform the material and substantial duties of your own job that you were performing when your disability began. Material and substantial duties means responsibilities that are normally required to perform your own job and cannot be reasonably eliminated or modified.
In some cases, you may be considered partially disabled if you can work on a limited basis. Partial disability means that as a result of injury or sickness, you are able to:
- Perform one or more, but not all, of the material and substantial duties of your own job or another job on an active employment or part-time basis, or
- Perform all of the material and substantial duties of your own job or another job on a part-time basis, and
- Earn between 20% and 80% of your basic weekly earnings.
All disability determinations will be made by the claims administrator.
Disability calculation
If you are disabled, your disability benefit is calculated as your basic weekly earnings multiplied by 65%.
If you are partially disabled, your disability benefit will be reduced by your return-to-work earnings, but not until your disability benefit plus your return-to-work earnings exceed 100% of your basic weekly earnings. For example, assume that your basic weekly earnings is $1,500 and you return to work on a part-time basis earning $800 per week. Your weekly disability benefit before any reductions is $975. $975 plus $750 equals $1,775 ($275 over $1,500). Your partial disability benefit would be $700 ($975 - $275).
Injury
Injury means bodily impairment resulting directly from an accident and independently of all other causes. Any disability which begins more than 60 days after an injury will be considered a sickness.
Physician
The definition of physician depends on where you reside:
- For Non-California participants, a physician means a person who is licensed to practice medicine and is practicing within the terms of his or her license, or a licensed practitioner of the healing arts in a category specifically favored under the health coverage laws of the state where the treatment is received and is practicing within the terms of his or her license. A physician does not include you, a family member, or a domestic partner.
- For California participants, a person who can provide certification of disability is defined as:
- Any licensed physician, surgeon, optometrist, dentist, osteopath, qualified licensed psychologist, accredited practitioner, chiropractor, or podiatrist who is practicing within the scope of his or her license.
- A licensed nurse-midwife or nurse practitioner who may certify only to normal pregnancy and childbirth related disabilities.
- An authorized medical officer of any facility of the United States government or an authorized practitioner who is accredited by the Director of the California Employment Development Department.
- If you in good faith adhere to the teachings of an organization, such as a church, sect or denomination, that depends on healing entirely by prayer or spiritual means, the certificate from a duly authorized or accredited practitioner of the organization is acceptable.
Sickness
Sickness means illness, disease, pregnancy, or complications of pregnancy.
When Benefits Begin and End
Benefits will begin on the eighth day of a disability.
Benefit payments will end on the earliest of:
- The date you fail to provide proof of continued disability (or partial disability) and regular attendance of a physician.
- The date you fail to cooperate in the administration of your claim (for example, you do not provide information or documents requested by the claims administrator to determine if a benefit is payable or the actual benefit amount).
- The date you refuse to be examined or evaluated at reasonable intervals.
- The date you refuse to receive appropriate available treatment.
- The date you refuse a job at Canon Medical Systems for which the Company has made modifications or accommodations that allows you to perform the material and substantial duties of the job.
- The date you are able to work in your own job on a part-time basis, but choose not to.
- The date your current partial disability earnings exceed 80% of your basic weekly earnings (earnings will be averaged over three consecutive weeks to allow for fluctuations).
- The date you are no longer disabled.
- The end of the maximum benefit period described below.
- The date you die.
California participants: In accordance with California law, under some of the situations listed above, your benefit may not end entirely but, instead, be reduced to the benefit level under the state disability insurance program (generally 60% of gross pay, as defined by the state, up to the state maximum). You will be advised if you are affected.
The maximum benefit period is the period for which a benefit is payable after you complete the elimination period. The maximum benefit period will end on the earliest of the date you are no longer disabled or the end of the 52nd week of disability. If you are still disabled and are unable to work after 52 weeks, you may be eligible for benefits from the Long Term Disability Plan.
Alcohol-Related Disabilities (California Employees Only)
The following disability period is for participants who have a disability solely related to alcoholism (i.e., no other disability exists). The plan will pay benefits for up to 30 days while you receive alcoholism recovery treatment as a participating resident of an approved alcoholism recovery home. Your physician must have referred or recommended the residential treatment. Benefit payments may be extended for up to 60 additional days provided the referring physician certifies the need for continuing resident services.
Drug-Related Disabilities (California Employees Only)
The following disability period is for participants who have a disability solely resulting from substance abuse (i.e., no other disability exists). The plan will pay benefits for up to 45 days while you receive drug recovery treatment as a participating resident of an approved drug-free residential facility. Your physician must have referred or recommended the residential treatment. Benefit payments may be extended for up to 45 additional days provided the referring physician certifies the need for continuing resident services.
Successive Periods of Disability
If you return to work following a period of disability for less than 60 days and then become disabled again due to the same or related cause or condition, your two periods of disability will be considered one disability benefit period. For purposes of this provision, return to work means that you are performing all the material and substantial duties of your own job and have experienced more than a 20% loss of basic weekly earnings. Benefit payments for the second disability period will begin immediately and both periods of disability will count toward a single maximum disability benefit period.
If you return to work for 60 days or more and then become disabled again, your subsequent disability will be treated as a new disability, even if it is related to a previous disability. You will be required to satisfy a new waiting period before benefit payments can begin and a new maximum disability benefit period will apply.
Your benefit will be reduced by other wages or benefits you receive as described in Other Income Benefits below. Please note that if you receive a plan benefit greater than you should have been paid, the Company or the claims administrator has the right to collect overpayment as specified in the plan, including but not limited to, the right to reduce future benefit payments.
Partial Weeks of Disability
Benefits for a partial week of disability will be prorated. If you have a partial week of disability, the daily benefit amount will be 1/7th of the weekly benefit amount.
Other Income Benefits
Your benefit payment from this plan will be reduced by the following benefits for which you receive or may be eligible to receive:
- Social Security or other government retirement and/or disability benefits, including benefits for your dependents because of your disability or retirement.
- A governmental program or coverage required or provided by statute, including any amount attributable to your family.
- Workers' or Workmen's Compensation benefits.
- Any work loss provision in mandatory "No-Fault" auto coverage.
- Unemployment benefits.
- Amounts received or awarded because you were injured by a third party, less any unreimbursed medical expenses awarded by a court and less reasonable expenses of collecting the amounts, including attorneys' fees.
The plan benefit will also be reduced by any lump sum amounts received by compromise, settlement or other method as a result of a claim for any of the other income sources listed above.
If you are eligible for any of the above benefits, you must provide the claims administrator with written evidence that you have applied for these benefits. You will then be asked to sign a promissory note to repay any benefit amount you expect to receive from other income sources. The claims administrator will pay you the full plan benefits while you are waiting for your "other" benefits to begin. Failure to sign the promissory note will result in a delay in the payment of all or some of your benefits payable under this plan.
If you are eligible for any of the above benefits and either choose to defer payment or not file a claim, the claims administrator will process the claim with the assumption that you started receiving the "other" benefit(s) when first eligible and reduce your benefit from this plan accordingly.